Clinical characteristics and prodrome of Vasovagal syncope(vvs) in young and old.

Transcription

1 Clinical characteristics and prodrome of Vasovagal syncope(vvs) in young and old. Clodagh O Dwyer, Ciara rice, Dymphna Hade, Lisa Byrne, Michelle Burke, CW Fan, RA Kenny Falls & Blackout Unit, St. James Hospital

2 Syncope C O'Dwyer - BGS Aut 2009 Cardiac arrhythmia Structural Heart disease Cerebrovascular Psychogenic Orthostatic Neurally Mediated Carotid sinus Syncope Vasovagal Syncope

3 Vasovagal Syncope (VVS) C O'Dwyer - BGS Aut 2009 Definition 40% one episode per lifetime benign Murdoch BD. S AfrMed J 1980;57: Ganzeboom et al, Am J card 2003;91: Age of onset Sheldon et al, J Card Elect 2006;17:49 54 Colman et al, Clin Auton Res 2004;14 suppl 1: % of recurrent syncope older adults Wieling et al, Mayo Clin proc 2003;78: Colman et al, Clin Auton Res 2004;14: suppl 1:9 17 Vasovagal syncope vs Vasovagal disease Brignole M. Hellenic J cardiol 2008;49:61 64

4 Proposed Mechanism: VVS

5 Prodrome Lightheadedness Palpitations Sweating Warm feeling Nausea/vomiting Blurred vision Dark vision Headache Hearing disturbance Rising stomach feeling Paraesthesia/tingling Pain neck/shoulder/a/l Yawning Giddy sensation

6 Triggers for VVS Standing Church Shopping Crowded environment Heat Exercise Postprandial Situational Coughing Micturition Defecation Medical settings Emotional stress

7 Diagnostic dilemmas in older adults Short prodrome Prodrome recall Guida et al. Europace july 2009 Amnesia for loss of consciousness (falls presentation) Parry et al. Can J cardiol 2002; 18(7): Kenny et al. JACC 2005; 45 (11): Higher tolerance to Head up tilt table (HUTT) testing Sheldon R. Am J Cardiol 1994;74(5):459 63

8 Aim To define clinical characteristics of VVS in older persons in comparison to that of younger: 1. Prodromal symptoms 2. Trigger factors 3. Amnesia for loss of consciousness

9 Methods 1 Recruitment Falls & Blackout Unit Consecutive new referrals with unexplained falls/syncope over a nine month period completed a 74 item Structured Questionnaire Cross checked for completion with clinical data ESC guidelines followed Head up tilt table(hutt) where indicated(mmse>26)

10 Methods 2 Type 3 Vasodepressor Type 1 Mixed Type 2 A Cardioinhibitory Type 2 B Cardioihibitory BP drop only BP drop with < 40bpm for < 10 sec +asystole < 3 sec BP drop with > 40 bpm for > 10 sec + asystole > 3 sec < 40 bpm for > 10 sec + asystole > 3 sec prior to or at time of BP drop QuickTime and a YUV420 codec decompressor are needed to see this picture. Loss of consciousness witnessed by supervising doctor and clinical nurse specialist Patients questioned on their recollection of LOC immediately post tilt back and prior to leaving the clinic.

11 Results: Pathway of Investigation Questionnaire (n=400) History & Examination ECG & Active Stand Diagnosis Cardiac Neuro CSM HUT(n=163) VVS Neg (n=69) VVS Pos (n=94)

12 Results: End diagnosis VVS (n=94) < 60 years > 60 years Number N=59 N=35 Mean age years years Female N=39 (66.1%) N=24 (68.6%) Male N=20 (33.9%) N=11 (31.4%) Unexplained falls N=24 (40.7%) N=15 (42.9%) Fractures due to falls or syncope N=6 (10.2%) N=8 (22.9%)

13 Age of onset of syncope (n=83) Age range

14 Warning symptoms(n=94) <60yrs(n=59) > 60yrs(n=35) P value OR(95%CI) Sweating 30 (50.8%) 11 (31.4%) [0.94,5.43] Lightheaded 47 (79.9%) 19 (54.3%) [1.31,8.26] Palpitations 20 (33.9%) 5 (14.3%) [1.04,9.17] Feeling Warm 31 (52.5%) 11 (31.4%) [1.00,5.81] Chest pain 8 (13.6%) 0 (0%) 0.02 Hearing dist. 9 (15.3%) 1 (2.9%) [0.74,50] Tingling 13 (22%) 3 (8.6%) [0.79,11.5]

15 Warning symptoms (n=94) Symptom Age < 60(n=59) Age > 60(n=35) P value OR[95%CI] Nausea 18 (30.5%) 14 (40%) [0.28,1.58] Vomiting 5 (8.5%) 2 (5.7%) [0.28,8.33] Feel Giddy 5 (8.5%) 5 (14.3%) [0.15,2.07] Funny stomach sensation 11 (18.6%) 11 (31.4%) [0.18,1.32] Yawning 0 (0%) 2 (5.7%) 0.06 Headache 10 (16.9%) 3 (6.8%) [0.56,8.55] Blurred vision 21 (35.6%) 8 (22.9%) [0.72,4.83] Dark Vision 19 (32.2%) 11 (31.4%) [0.42,2.54] Arm/Leg pain 6 (10.2%) 2 (5.7%) [0.36,9.8] Neck/shoulder pain 5 (8.5%) 2 (5.7%) [0.28,8.33] Short of breath 13 (22%) 4 (11.4%) [0.65,7.35]

16 Triggers for VVS < 60 yrs(n=59) > 60 yrs(n=35) P value OR[95%CI] Standing 27 (45.8%) 17 (48.6%) [0.39,2.07] Postprandial 4 (6.8%) 4 (11.4%) [0.13,2.41] Venepuncture/ sight of Blood 8 (13.6%) 0 (0%) Post exercise 6 (10.2%) 0 (0%) 0.05 Stress 11 (18.6%) 1 (2.9%) [0.96,62.5]

17 Loss of consciousness(loc) on HUTT Age < 60 (n=59) Age > 60 (n=35) P value Difference between groups OR(95%CI) LOC (n=55) Amnesia Immediate 33 (56%) 22 (62%) [0.32,1.81] 9 (27%) 13 (59%) [1.23,12] Delayed Amnesia 6 (18%) 10 (45%) [1.10,12.6]

18 HUTT response(n=55) Type 3 Pure Vasodepressor response Type 1 Mixed response Type 2A (Cardio inhibitory) Type 2B (Cardio inhibitory) Amnesia(n=16) No Amnesia(n=39) 12(75%) 23(59%) 1(6%) 3(8%) 2(13%) 7(18%) 1(6%) 6(15%)

19 Discussion Lack of hypotensive awareness increases with age in Vasovagal syncope Amnesia for preceding prodrome and for loss of consciousness is greater in older adults. Risk: Unexplained falls and fractures VVS should be eliminated in those with normal cardiac workup with an otherwise unexplained fall/syncopal event Treatable condition

20 Where to from here?. Why are symptoms and amnesia more prominent in some more than others? Pure haemodynamic/autonomic effect? Correlate Tilt Blood pressure and heart rate response to onset of symptoms and presence of amnesia Independent cerebral component? EEG and TCD studies